The latest buzzword in back surgery is “minimally invasive.” Chances are you’ve heard or seen this phrase in ads for back pain clinics around the country. Smiling patients emerge from surgery centers looking none the worse for wear, holding hands with their spouses and playfully scooping up grandkids.
More and more medical centers promote minimally invasive surgery as a quick and simple alternative to traditional surgery. But is it really better? And is it right for you?
Finding answers isn’t as easy as you’d like to think.
When it comes to any kind of back surgery, the best advice depends on many factors, including your health, the nature of your back problem, and your doctor’s expertise.
As for minimally invasive techniques for back surgery, even researchers have had trouble determining if they are better than traditional “open” surgery. First, there’s the question of exactly what “minimally invasive” means.
Most patients assume that it simply involves a smaller incision and, as a result, a smaller scar. That’s true. But a more meaningful definition is surgery that damages as little healthy tissue as possible.
For lower back pain, a variety of different minimally invasive techniques are used. And new techniques are evolving.
Whatever the technique, it seems safe to assume that any surgery that involves a smaller incision and less disruption will also mean faster recovery. Indeed, many studies do show that patients who undergo minimally invasive techniques recover faster.
In an article published in 2014 in Clinical Orthopaedics and Related Research, experts reviewed findings from seven studies comparing minimally invasive lumbar fusion surgery with conventional “open” surgery. They found that minimally invasive surgery resulted in less blood loss and shorter hospital stays.
In a similar analysis, also published in 2014 in the same journal, a team of Canadian researchers looked at findings from 27 studies. They arrived at the same conclusion: minimally invasive lumbar surgery resulted in less blood loss and shorter hospital stays. In many cases, patients were able to leave the hospital at least one day and sometimes several days earlier than patients undergoing “open” surgery.
But when researchers examine whether patients who have minimally invasive spinal surgery fare better over time than conventional surgery patients do, the evidence gets murky.
Researchers at Zhejian University in China reviewed findings from a variety of studies that included a total of 785 patients. In an article published in 2013 in the European Spine Journal, they reported mixed results.
Three studies showed that people undergoing minimally invasive surgery experienced greater improvement in leg and back pain than those who had conventional open surgery. But two studies showed that open surgery patients did better. One study showed no difference at all between the two kinds of surgery when it came to leg and back pain improvement.
Advocates of minimally invasive surgical techniques often claim that there are fewer complications. But here, too, the evidence isn’t very persuasive.
When researchers at Thomas Jefferson University in Philadelphia compared complication rates in minimally invasive spinal surgery versus open surgery, looking at results from 14 studies, they found no significant differences.
Their results, published in 2013 in Seminars in Spine Surgery, showed that infection rates and the need for follow-up surgery were the same. Their conclusion: minimally invasive approaches “did not confer any statistically significant advantage over traditional surgery for any of the complications reviewed.”
Surprisingly, some studies warn that minimally invasive techniques may actually pose distinct dangers. One worry is radiation exposure. To guide the tiny instruments that are used to perform minimally invasive surgery, doctors use an imaging device called a fluoroscope, which emits X-rays.
In a 2013 study published in The Spine Journal, researchers compared 162 patients who had received either minimally invasive or open surgery for spinal fusion. They found that patients in the minimally invasive group were exposed to seven times more fluoroscopy than those in the open surgery group (1.5 minutes compared to 0.2 minutes).
The radiation exposure in that short amount of time is relatively low. Placement of a pacemaker, for example, may require 30 minutes of fluoroscopy. Still, the less radiation that patients—and medical teams—are exposed to, the better.
Another worry is nerve damage during minimally invasive surgery. In their review of 14 studies, the Thomas Jefferson University researchers found that root nerve injuries occurred in 2.9 percent of patients receiving minimally invasive surgery. None of the patients who underwent conventional open surgery suffered similar nerve damage.
Other studies have also found a higher risk of nerve damage associated with minimally invasive techniques. In a 2016 editorial in the journal Surgical Neurology International, neurosurgeon Nancy Epstein, M.D., of Winthrop University Hospital in New York, warned that nerve root injuries were much more common following almost any kind of minimally invasive spinal surgery technique than in open surgery.
Adding it all up
Whenever new approaches to surgery come along, it’s important for researchers to make sure they are really better than previous techniques. But making those comparisons can be challenging.
Patients differ. Surgeons vary in their experience and expertise. Different studies come up with conflicting results.
Still, for now, the evidence suggests that minimally invasive surgery may mean a shorter hospital stay and less blood loss during the operation. But on many measures, the less-invasive techniques seem to be about the same as conventional open surgery.
Reduction in pain and improvements in function afterward are similar, for example, according to most studies. And there are certainly reasons to be cautious. Minimally invasive surgery does expose patients to more radiation, and there appears to be a higher risk of nerve damage.
As always, the best advice is to talk to your doctor about what he or she recommends, and why. Discuss any concerns or worries you have. When appropriate, get a second opinion.
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